Research Commentary [29] March 2019

Mar 8, 2019

Research Commentary [E29] March 2019

This review focuses on effective models of mental health care for refugees.

This review is in response to the unprecedented upsurge in the number of refugees worldwide, the New Zealand Government has increased the refugee quota from 2019 to 1500 quota refugees annually. The review considers contemporary issues in the refugee mental health field, including developments in research, conceptual models, social and psychological interventions and policy. Ideally, resettlement countries should offer social and therapeutic interventions, integration in mainstream mental health services, rehabilitation and special programmes for vulnerable groups. This review and the previous Asian mental health review are useful information for the development of effective models of mental health care for refugee and migrant populations in New Zealand.

Commentary provided by Dr Annette Mortensen, eCALD® Services Project Manager: Research and Development

The following articles are reviewed:

Article 1: Addressing Mental Health Needs of Refugees.

This study asks the questions “What is the evidence available to respond effectively to the mental health needs of refugees? And what are the associated training needs for psychiatrists? In relation to the latter question, recent research on the social determinants of refugee mental health shows the importance of income, housing, employment, immigration procedures, and discrimination as risk factors for refugee mental health, suggesting that psychiatrists may improve refugee mental health by advocating for a public mental health approach to resettlement.

Although limited, there are significant ways in which mental health providers and psychiatrists can make a difference for refugee mental health, beyond the clinician’s commitment to compassion and good quality. The authors recommend training. Registrar training and continuing education can promote cultural competence training programmes to address refugee mental health. The Transcultural Psychiatry of the Canadian Psychiatric Association (CPA) Guidelines set out the rationale, content and pedagogical strategies for training in cultural psychiatry (Kirmayer et al., 2012). The CPA training guidelines propose training approaches that could be useful to help services address contemporary refugee resettlement challenges in receiving societies. The guidelines are useful in informing the emerging field of cross-cultural psychiatry in New Zealand, a response to our growing ethnic diversity and the complexity of cultural presentations.

Approaches to models of service which are phased to prioritise non-specific psychosocial interventions until some emotional and social safety is established, are more needed than ever. Nonspecific psychosocial interventions targeting baseline safety, employment, education, and immigration status are at the forefront during resettlement.

This study supports the view that ongoing social conditions exert a powerful impact on the mental health and psychosocial well-being of refugees. In addition to the effects of past trauma, refugees commonly confront important challenges and stressors in their new environments, including ongoing insecurity, difficulty accessing essential services (health, mental health, education), lack of opportunities for employment, and more generally, host society attitudes of racism and discrimination. Death, disappearances and separations result in persisting grief and loss. The ongoing consequence of these losses is that refugees commonly lack the support of nuclear and extended families and other traditional networks, a profound challenge for communities with strong collectivist values. Even in intact families, relationships can be undermined by the cumulative effects of past trauma and ongoing stressors, resulting in conflict and, at worst, intimate partner violence.

Social programs for refugees have the potential to revive a sense of connectedness, re-establish social networks, and promote self-help activities. Strategies that foster community initiatives encourage a sense of control and engagement in the task of self-directed recovery, counteracting the inertia, dependency, and inter-group divisions that characterise many transitional refugee settings. There are compelling theoretical, economic, and strategic reasons, therefore, to give priority to social interventions in the array of strategies aimed at relieving distress and promoting well-being amongst refugees.

Article 3: Psychological distress is influenced by length of stay in resettled Iraqi refugees in Australia.

Iraqi refugees have been settling in New Zealand over the past two decades. This Australian study has significance for the long-term mental health outcomes of Iraqi families settled in New Zealand. Resettled Iraqi refugees have been identified as a highly vulnerable group with reports indicating they present with higher degrees of emotional trauma and poorer health compare to other refugee groups. This study shows that Iraqi refugees with longer lengths of stay in Australia have chronic or increased levels of psychological distress over time. In particular, the observed difference was greater in the 45–54 age groups. Levels of severe psychological distress were significantly higher among Iraqi refugees compared to the general Australian population.

One factor which may be related to increased levels of psychological distress over time is evidence of underutilisation of mental health services and the generalised stigma associated with mental health problems amongst refugees. Evidence of low levels of mental health literacy in Iraqi refugees, namely, a lack of recognition of mental health disorders and a lack of knowledge of treatment options or of professional services provides an area of potential targeted intervention. One way forward is to develop appropriate community and individual psycho-education programmes for refugee communities, which could have a positive impact on help-seeking behaviours. Developing better guidelines for those working in resettlement agencies, health, welfare and education providers so that they are better equipped to respond to mental health crises and offer mental health first aid would be beneficial. Similarly, general practitioners and other health professionals should be kept aware that the psychological issues which commonly affect those from refugee backgrounds can persist for many years, and may even worsen.

The New Zealand Government has accepted Syrian refugees as part of the annual refugee quota since 2015. This article shares World Health Organization (WHO) initiatives to foster responsive mental health services for Syrian refugees in neighbouring and resettlement countries. The crisis in Syria has resulted in vast numbers of refugees seeking asylum in Europe. To counter some of the challenges arising from limited mental health system capacity, WHO has developed a range of scalable psychological interventions aimed at reducing psychological distress and improving functioning in refugee populations. These interventions are intended to be delivered through individual or group face-to-face or smartphone formats by lay, non-professional people who have not received specialised mental health training. One of these programmes, Problem Management Plus (PM+), provides short multi-behavioural group and individual interventions, delivered over five weekly sessions. This is a multicomponent approach and based on evidence-based Cognitive Behavioural Therapy (CBT) and Psychological Training Skills (PST) strategies. These may be delivered by nonprofessional helpers in community or primary care settings or by lay people such as peer-refugees after approximately 10 days of training followed by weekly group supervision by a trained clinician. Clients are taught four strategies: stress management (slow breathing exercises); problem solving (proactive management of practical difficulties through a series of sequential steps including selection of problems, brainstorming for solutions, planning implementation of solutions); behavioural activation (re-engaging with pleasant and task-oriented activities); and skills to strengthen social support.

The outcome of the STRENGTHS study, which aims to evaluate whether implementation of the WHO programmes improves the functioning and responsiveness of mental health systems to refugees in Europe will be of interest to New Zealand mental health service providers in areas where refugees are being settled.

Article 5: Effectiveness of Primary Health Care Services in Addressing Mental Health Needs of Minority Refugee Population in New Zealand.

This New Zealand study is one of the few to study mental health needs in Bhutanese refugee populations. Bhutanese refugees are Bhutanese citizens of Nepali origin who are known as Lhotsampas (people of the South). More than 100,000 Lhotsampas fled or were forced to leave Bhutan during 1991–1992. It has been more than ten years since the UNHCR began resettling Bhutanese refugees in refugee resettlement countries including New Zealand. This study provides insights into Bhutanese refugee women’s mental wellbeing after resettlement in New Zealand.

In the study, Bhutanese women reported significant ‘mental tension’. They attributed their tension to language difficulties, being away from their extended family, financial constraints and lack of employment opportunities. None of the Bhutanese women and men interviewed were aware of any mental health related supports or services available to them. Health professional interviews further affirmed that assessment, treatment and referral for mental health problems for Bhutanese refugee women had not been a priority in primary health practices.

This study identified gaps in adopting a multi-sectoral approach to addressing the wider social, cultural, political, and economic factors that have been affecting Bhutanese women’s health and mental health. For example, unemployment and financial constraints impacted negatively on Bhutanese women’s health and wellbeing post-resettlement. Strategies to support Bhutanese women’s employment opportunities to promote their self-esteem and overall wellbeing would go a long way to improving their mental health. The choice of resettlement location has also had a significant impact on Bhutanese women’s spiritual wellbeing and ability to cope. The majority of Bhutanese women follow the Hindu religion but there is no local Hindu temple in any of the areas where Bhutanese refugees have been settled. This finding is informative in consideration of further settlement locations for new refugee communities to New Zealand. For communities, continuing socio-cultural and religious practices collectively on a regular basis, contributes not only to keeping cultural heritages and ethnic identities alive but is also an important factor in maintaining good physical and mental health.

Article 6: Impacts of social integration and loneliness on mental health of humanitarian migrants in Australia: Evidence from a longitudinal study.

This study is one of the first to assess time trends for the general and mental health status, and to examine the effect of changing resettlement-related post-migration stressors, on Humanitarian Migrants (HMs’) health over time. The study found that mental health indicators for HMs, including severe mental illness (SMI) and PTSD, followed U-shape trajectories during the first three years of resettlement in Australia. The prevalence of SMI and PTSD decreased from baseline to the first wave of follow-up (the second year of resettlement) while increasing in the second wave of follow-up (the third year of resettlement). Decreasing rates of mental health issues during the first year might be a developmental consequence of the HMs’ positive experience of resettlement. During initial resettlement, refugees experience the relief of finding security in hosting countries, while enjoying access to a range of social and welfare services.

Except for the persistent and high prevalence of mental health problems and the aging effect, poor access to and inadequate use of healthcare in host countries may be a significant contributor to the deterioration in general health among HMs. Although hosting countries’ governments have made efforts to improve healthcare services for HMs, such as free interpreting services and guidelines for cultural competence in healthcare, HMs with health problems still experience systemic and sociocultural barriers to health service access and lack the competence to use available services.

An important finding in this study is that changes in social integration and loneliness during resettlement have significant impacts on HMs’ health over time. Specifically, HMs with loneliness or social integration stressors during resettlement had worse general or mental health status over time than those without these post-migration stressors, regardless of the subsequent change in stressor status. HMs, who experienced an increase in loneliness and the number of social integration stressors, or experienced loneliness and social integration stressors but overcame them over time, had poorer physical and mental health than those who had never had stressors.

The findings call for attention to the need for psychosocial programmes to help HMs establish healthy social relationships, for example, by encouraging individuals in similar circumstances to share interpersonal difficulties and strategies. In addition, the design of psychosocial programmes and other settlement services needs to take cultural factors into consideration, because the findings suggest that HMs with different backgrounds and countries of origin had differing health status after resettlement.

Authors: Chen, W., Wu, S., Ling, L., Renzaho, A. M. N.

Citation: Chen, W., Wu, S., Ling, L., Renzaho, A. M. N. (2019). Impacts of social integration and loneliness on mental health of humanitarian migrants in Australia: Evidence from a longitudinal study. Australian and New Zealand Journal of Public Health, Early View. doi.10.1111/1753-6405.12856.